Wellness Check In
Your Annual Physical is coming up and we want to maximize our time with you. Please take a moment to give us an update on what's going on with you! Don't have all the answers to these? That's ok! Fill out what you can and bring the rest to your upcoming appointment. IF YOU DO NOT ANSWER THESE QUESTIONS, PLEASE KNOW WE WILL ASK THEM AT YOUR APPOINTMENT. We look forward to seeing you!
Name
First Name
Last Name
Please describe any health concerns you have:
Please List your current medications (dose/prescriber included if possible)
Please list your current supplements (brand/dose included if possible)
Please list your doctors/care team, including our doctors.
Do you have any allergies?
Any new diagnoses, surgeries or other medical events?
How is your family? Any new family history we should know about?
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How up to date are you with immunizations?
Please submit the dates of the vaccines you have recently gotten. If you are unsure, an approximate date can work. Please UPLOAD or BRING any proof of vaccinations you have.
Influenza/Flu vaccine
-
Month
-
Day
Year
Date
I cannot recall when I had a flu vaccine.
I have not had a flu vaccine.
Tetanus Vaccine
-
Month
-
Day
Year
Date
Type a question
I cannot recall getting a tetanus vaccine.
I have not had a tetanus vaccine.
COVID Vaccine
-
Month
-
Day
Year
Date
Type a question
I do not plan to have a covid vaccine.
Covid Vaccine (Second shot, if applicable)
-
Month
-
Day
Year
Date
Which COVID Vaccine did you get?
Please Select
Johnson and Johnson
Pfizer
Moderna
HPV Vaccine (If applicable)
-
Month
-
Day
Year
Date
Type a question
I have not had the HPV vaccine.
Shingles Vaccine (If applicable)
-
Month
-
Day
Year
Date
Which Shingles vaccine did you have?
I have not had a shingles vaccine.
Zostavax
Shingrix
I don't know.
Pneumonia Vaccine (If applicable)
-
Month
-
Day
Year
Date
Type a question
I have not had a pneumonia vaccine.
Anything regarding vaccines you would like the doctor to know about?
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Prevention Self Care
Let's get on the same page with all your screenings! Please approximate dates as best as possible. Some of these you may not have done yet. And that's ok! We just want to know so we can help you be on top of these important health screenings.
When was your last dental cleaning?
-
Month
-
Day
Year
Date
When was your last eye exam?
-
Month
-
Day
Year
Date
When was your last dermatology exam (skin check)?
-
Month
-
Day
Year
Date
When was your last colonscopy?
-
Month
-
Day
Year
Date
When was your last bone density screening?
-
Month
-
Day
Year
Date
When was your last well woman exam?
-
Month
-
Day
Year
Date
When was your last mammogram?
-
Month
-
Day
Year
Date
When was your last pap smear?
-
Month
-
Day
Year
Date
When was the first day of your last period?
-
Month
-
Day
Year
Date
How often do you perform self breast/testicular exams?
Please Select
Monthly
Rarely
Never
Things I want my doctor to know...
Use this space to share anything you might want to update your doctor on.
Please feel free to attach any documents, labs, imaging that you would like in your medical chart.
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Thank you for completing your Wellness Visit Pre-Check!
This helps us have more time with you and be as accurate as possible. We look forward to seeing you!
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